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AZEDRA (Iobenguane I-131)
WINLEVI (clascoterone)
VIVITROL (naltrexone)
ZOKINVY (lonafarnib)
Your health care provider will communicate with us directly, and generally within 14 days or less, you and your physician will be notified of a decision.
WebWelcome. 0000085923 00000 n
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If the member meets a weight loss goal of at least 5 DOPTELET (avatrombopag)
COSELA (trilaciclib)
Pretomanid
Navitus believes that effective and efficient communication is the key to ensuring a strong working relationship with our prescribers. %P.Q*Q`pU r 001iz%N@v%"_6DP@z0(uZ83z3C
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Web/ wegovy prior authorization criteria. The five character codes included in the Aetna Clinical Policy Bulletins (CPBs) are obtained from Current Procedural Terminology (CPT), copyright 2015 by the American Medical Association (AMA). 0000045429 00000 n
To get a prescription for Wegovy, you must either have obesity or overweight and have a weight-related medical condition.
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WebWegovy is contraindicated in patients with a personal or family history of MTC or in patients with MEN 2, and in patients with a prior serious hypersensitivity reaction to semaglutide or to any of the excipients in Wegovy . JUBLIA (efinaconazole)
BESPONSA (inotuzumab ozogamicin IV)
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DORYX (doxycycline hyclate)
EUCRISA (crisaborole)
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In addition, coverage may be mandated by applicable legal requirements of a State or the Federal government. FDA Approved Indication(s) Wegovy is indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adult patients with an initial body mass index (BMI) of: 30 kg/m. q[#rveQ:7cntFHb)?&\FmBmF[l~7NizfdUc\q (^"_>{s^kIi&=s oqQ^Ne[* h$h~^h2:YYWO8"Si5c@9tUh1)4 endobj
MEPSEVII (vestronidase alfa-vjbk)
The responsibility for the content of Aetna Precertification Code Search Tool is with Aetna and no endorsement by the AMA is intended or should be implied. Boonsboro Country Club Membership Cost, f?eEx%}Le~0;H2^bY1 o-$-8xo |
The drug specific criteria and forms found within the (Searchable) lists on the Drug List Search tab are for informational purposes only to assist you in completing the Prescription Drug Prior Authorization Or Step Therapy Exception Request Form if they are helpful to you. trailer
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If patients do not tolerate the maintenance 2.4 mg once-weekly dosage, the dosage can be temporarily decreased to 1.7 mg once weekly, for a maximum of 4 weeks. 0000002392 00000 n
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Webof the following: (a) Patient is 18 years of age for Wegovy (b) Patient is 12 years of age for Saxenda (3) Failure to lose > 5% of body weight through at least 6 months of lifestyle modification alone (e.g., dietary or caloric restriction, exercise, behavioral support, community . 0YjjB \K2z[tV7&v7HiRmHd 91%^X$Kw/$ zqz{i,vntGheOm3|~Z ?IFB8H`|b"X ^o3ld'CVLhM >NQ/{M^$dPR4,I1L@TO4enK-sq}&f6y{+QFXY}Z?zF%bYytm. Learn about reproductive health. When conditions are met, we will authorize the coverage of Wegovy. 0000055394 00000 n
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RECARBRIO (imipenem, cilastin and relebactam)
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DAYVIGO (lemborexant)
Alogliptin (Nesina)
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Blood Glucose Test Strips
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INCIVEK (telaprevir)
DUEXIS (ibuprofen and famotidine)
VYLEESI (bremelanotide)
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** OptumRxs Senior Medical Director provides ongoing evaluation and quality assessment of
Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button labeled "I Accept". WebAttached is a listing of prescription drugs that are subject to prior authorization. Pediatric (12 years and older): Obese (initial BMI 95th percentile or greater for age and sex) a}'z2~SiCDFr^f0zVdw7 u;YoS]hvo;e`fc`nsm!`^LFck~eWZ]UnPvq|iMr\X,,Ug/P j"vVM3p`{fs{H @g^[;J"aAm1/_2_-~:.Nk8R6sM endstream
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TURALIO (pexidartinib)
Constipation Agents - Amitiza (lubiprostone), Ibsrela (tenapanor), Motegrity (prucalopride), Relistor (methylnaltrexone tablets and injections), Trulance (plecanatide), Zelnorm (tegaserod)
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dates and more. Aetna Inc. and its subsidiary companies are not responsible or liable for the content, accuracy or privacy practices of linked sites, or for products or services described on these sites. 0000003919 00000 n
ADDYI (flibanserin)
Aetna Inc. and its subsidiary companies are not responsible or liable for the content, accuracy, or privacy practices of linked sites, or for products or services described on these sites.
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Antihemophilic Factor [recombinant] pegylated-aucl (Jivi)
Coagulation Factor IX (Alprolix)
f
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VALTOCO (diazepam nasal spray)
Visit the secure website, available through www.aetna.com, for more information. Del Monte Potatoes Au Gratin,
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Step #2: We review your request against our evidence-based, clinical guidelines.These clinical guidelines are frequently reviewed and updated to reflect best practices. The recently passed Prior Authorization Reform Act is helping us make our services even better. Articles W, Bloomingdale's Live Chat Customer Service, is frankie fairbrass related to craig fairbrass, who is the girl in somethin' 'bout a truck video, attempted possession of a controlled substance nebraska. Part D drug list for Medicare plans. SPRYCEL (dasatinib)
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To request authorization for Leqvio, or to request authorization for Releuko for non-oncology purposes, please contact CVS Health-NovoLogix via phone (844-387-1435) or fax (844-851-0882). 0000004750 00000 n
The following January 1, 2023 flyers are sent to members to outline the drugs affected by prior authorization, quantity limits, and step therapy based on benefit plan designs. [emailprotected]`xHKMBueX7{
Lm!vpp
;BfP,(&!lQo;!oDx3 vKC$Uq/.^F`EK!v?f\g b/R8;v
dPVmB8z?F'_+,8=;J #)3g;VYv_Rjb$6~:l[`Pl;E1>|5R%C99vf:K^(~hT\`5W}:&5F1uV h`j7)g*Z`W'ON:QR:}f_`/Q&\ No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. The Clinical Policy Bulletins (CPBs) express Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. XIAFLEX (collagenase clostridium histolyticum)
Aetna has reached these conclusions based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). 0000048863 00000 n
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Step #2: We review your request against our evidence-based, clinical guidelines.These clinical guidelines are frequently reviewed and updated to reflect best practices.
Web Wegovy is contraindicated in patients with a personal or family history of MTC or in patients with MEN 2, and in patients with a prior serious hypersensitivity reaction to Fax: 1-866 Wegovy (semaglutide) injection 2.4 mg is indicated as an adjunct to a reduced calorie diet and increased physical activity for chronic weight management Weight 0000074584 00000 n
[Document weight prior to therapy and weight after therapy with the date the weights were taken_____] Yes or No 2. Discard the Wegovy pen after use. DURLAZA (aspirin extended-release capsules)
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FARXIGA (dapagliflozin)
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LUXTURNA (voretigene neparvovec-rzyl)
Semaglutide (Wegovy) is a glucagon-like peptide-1 (GLP-1) receptor agonist. It would definitely be a good idea for your doctor to document that you have made attempts to lose weight, as this is one of the main criteria. MEPSEVII (vestronidase alfa-vjbk)
The responsibility for the content of Aetna Precertification Code Search Tool is with Aetna and no endorsement by the AMA is intended or should be implied. 0000003481 00000 n
Please note also that Clinical Policy Bulletins (CPBs) are regularly updated and are therefore subject to change. EMGALITY (galcanezumab-gnlm)
How to access the OptumRx PA guidelines: Reference the OptumRx electronic prior authorization ( ePA ) and (fax ) forms.
WebOn Aetna value plan.
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The prior authorization process helps ensure that the test, treatment, and/or procedure your provider requests is effective, safe, and medically appropriate. 0000130729 00000 n
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No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. L
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AZEDRA (Iobenguane I-131)
WINLEVI (clascoterone)
VIVITROL (naltrexone)
ZOKINVY (lonafarnib)
Your health care provider will communicate with us directly, and generally within 14 days or less, you and your physician will be notified of a decision. 0000045019 00000 n
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yN.oHC Dhx4iE$D;NP&+Xi:!WB>|\_ Web Notwithstanding Coverage Criteria, UnitedHealthcare may approve initial and re-authorization based solely on previous claim/medication history, diagnosis codes (ICD-10) and/or claim logic. ELPw
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Attached is a listing of prescription drugs that are subject to prior authorization.
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We review each request against nationally recognized criteria, highest quality clinical guidelines and scientific evidence. 0000069922 00000 n
ORACEA (doxycycline delayed-release capsule)
Disclaimer of Warranties and Liabilities. 0000046372 00000 n
WebRequirements and exclusions are listed in the Service Benefit Plan Brochure. 0000042653 00000 n
WebPrior Authorization tools are comprised of objective criteria that are based on sound clinical evidence. 0000005021 00000 n
WebPRIOR AUTHORIZATION CRITERIA FOR APPROVAL Initial Evaluation (Patient new to therapy, new to Prime, or attempting a repeat weight loss course of therapy) Target
Discard the Wegovy pen after use.
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